Effectively Communicating with Patients about Opioid Therapy
NOTE: This transcript has not been reviewed by the presenters and is made available solely for your convenience. A final version of the transcript will be posted as soon as the presenter’s review is complete. If you have any questions concerning this transcript, please send an email to firstname.lastname@example.org.
Moderator: Dr. Loretta Jackson-Brown
Presenters: Deborah Dowell, MD, PhD; David J. Tauben, MD, FACP, MD; Joseph O Merrill, MD, MPH
Date/Time: December 13, 2016, 2:00 – 3:00 pm ET
Coordinator: Welcome and thank you for standing by. At this time all participants are in a listen-only mode. During the question and answer session please press Star 1 and record your name as prompted. Today’s conference is being recorded. If you have any objections you may disconnect at this time. I would now like to turn today’s meeting over to Dr. Loretta Jackson-Brown. Thank you, you may begin.
Dr. Loretta Jackson-Brown: Thank you (Carolyn). Good afternoon. I’m Dr. Loretta Jackson-Brown and I’m representing the Clinician Outreach and Communication Activity, COCA with the Emergency Risk Communication Branch at the Centers for Disease Control and Prevention. I’m delighted to welcome you to today’s COCA call, Effectively Communicating with Patients about Opioid Therapy.
You may participate in today’s presentation by audio only, via webinar or you may download the slides if you are unable to access the webinar. The PowerPoint slide set and the webinar link can be found on our COCA webpage at emergency.cdc.gov/coca. Free continuing education is offered for this COCA Call. Instructions on how to earn continuing education will be provided at the end of the call.
CDC our planners, presenters and their spouses, partners wish to disclose they have no financial interest or other relationships with the manufacturers of commercial products, suppliers of commercial services or commercial supporters with the exception of Dr. David Tauben and Dr. Joseph Merrill. They would like to disclose that their employer the University of Washington received a contract payment from the Centers for Disease Control and Prevention. Planners have reviewed content to ensure there is no bias. This presentation will include discussion of the unlabeled use of a product or products under investigational use.
At the end of the presentation you will have the opportunity to ask the presenters questions. On the phone dialing star 1 will put you in the queue for questions. You may submit questions through the Webinar system at any time during the presentation by selecting the Q&A tab at the top of the Webinar screen and typing in your question. Questions are limited to clinicians who would like information on prescribing opioids. For those with media questions please contact CDC Media Relations at 404-639-3286 or send an email to email@example.com . If you are a patient please refer your questions to your healthcare provider.
At the conclusion of this session the participant will be able to outline key talking points to communicate to a patient who has been prescribed opioid therapy, provide practical strategies to help motivate a patient’s commitment to opioid therapy adjustment and apply a patient centered six-step process to minimize conflict when communicating opioid dosing recommendations. COCA is excited to partner with CDC’s National Center for Injury Prevention and Control to offer this seven call series on CDC Guideline for Prescribing Opioids for Chronic Pain. Missed the call? No worries. View call recordings and earn free continuing education by visiting our COCA webpage.
Today’s first presenter is Dr. Deborah Dowell. Dr. Dowell is Senior Medical Advisor for the National Center for Injury Prevention and Control at the Centers for Disease Control and Prevention. She previously led CDC’s Prescription Drug Overdose Team and served as advisor to New York City Health Commissioner. Dr. Dowell is lead author of the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain.
Our second presenter Dr. David Tauben is Chief of the Division Pain Medicine at the University of Washington. He has nearly 30 years of clinical practice experience in primary care internal medicine. He is board certified in both internal medicine and pain medicine. Dr. Tauben is a Director, a Medical Student in Resident Education and Pain Medicine at the University of Washington. Jointly appointed in the Department of Medicine in Anesthesia and Pain Medicine Dr. Tauben served as a Reviewer for the 2016 CDC Guideline for Prescribing Opioids and Chronic Pain.
Today’s third presenter Dr. Joseph Merrill is an Associate Professor in the Department of Medicine at the University of Washington. He has extensive clinical, teaching and research experience in addiction medicine and opioid prescribing for chronic non-cancer pain. Board-certified in addiction medicine by the American Board of Addiction Medicine Dr. Merrill developed both methadone maintenance and buprenorphine programs and primary care settings. He is a telemedicine panel expert in chronic pain, Hepatitis C and opioid addiction programs.
As a reminder the PowerPoint slides that in the webinar link can be found on our COCA webpage at emergency.cdc.gov/coca. At this time please welcome Dr. Dowell.
Dr. Deborah Dowell: Thank you Dr. Jackson-Brown. Today’s webinar content on effective communication with patients about opioid therapy is based on the CDC Guideline for Prescribing Opioids for Chronic Pain. Released in March in the Morbidity and Mortality Weekly Report and in JAMA. Today I’m going to focus on three types of clinical situations where good communication with patients is especially important and potentially challenging but where there are specific things you can do to increase your effectiveness, communicating important information, motivating behavior change and addressing conflicts between patient requests and your clinical judgment.
Recommendation three in the CDC Guideline for Prescribing Opioids for Chronic Pain states that before starting and periodically during opioid therapy clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy. This slide summarizes key information to convey to patients about opioids. We don’t know how well opioids work long term and they probably won’t take away your pain completely. Opioids can cause you to stop breathing and die especially at high doses or if taken with alcohol or other drugs. You could develop a serious lifelong addiction. Opioids can cause constipation, dry mouth, nausea, vomiting, withdrawal, drowsiness and might make driving unsafe.
We’ll meet often to make sure the medicine is not harming you. I test urine and check a database showing medicines from other doctors to be sure all my patients on opioids are safe. Those points took about a minute. It is a lot for patients to take in all at once. When communicating important information like benefits and risks of opioids, pause frequently and ask the patient what they heard you say. Correct any misunderstandings and ask if they have questions. It’s important to allow time for this process.
If you’re considering starting opioids and there isn’t sufficient time to go over this information during the visit think about waiting to start opioids until you have sufficient time to review this information with the patient. The next two situations we’ll discuss can involve emotional content and conflict. Two communication principles can take you a long way in successfully managing these situations. Approach patients with compassion and use relationship building skills such as reflective listening and empathetic statements.
The supporting text for recommendation 5 of the CDC Guideline of Prescribing Opioids for Chronic Pain addresses what to do if you have patients who are already prescribed high dosage of opioids. This can be a difficult situation for both clinicians and patients. Inheriting a patient on high opioid dosages can be frustrating and it can sometimes seem like you don’t have control over the situation.
At the same time many patients find the possibility of opioid doses reduction after years on high doses to be anxiety provoking. The guideline recommends explaining that new scientific evidence shows overdose risk increases at higher opioid dosages, empathetically reviewing benefits and risks of continued high dose opioids and offering to work with patients to taper to a safer dose. More guidance on tapering can be found in webinar 4 from this COCA series on dosing and titration of opioids and in our Tapering Guide as www.cdc.gov/drug/overdose .
But how do you get patients to the point of considering an opioid taper? Motivational interviewing can be an effective way to move patients towards readiness for change. Here are five principles of motivational interviewing from Miller’s and Rolnick’s classic book. I’ll go through these one at a time with examples of communication with a patient who is not yet willing to consider tapering opioids.
First illicit patient concerns with open ended questions. For example, “What concerns do you have about opioids?” Listen, reflect and express appropriate empathy. For example, “The idea of changing your opioid dose after all of these years must be frightening.” Next develop discrepancy between the patient’s goals and values and their current behavior. This is much more effective if you reflect back content that comes from the patient. We found in the contextual evidence review for the guideline that many patients on long term opioid therapy feel ambivalent about opioids.
You can often elicit ambivalent statements with nonjudgmental reflective listening. You can also ask the patient about their own goals and ask how opioids help or don’t help. Next reflect any ambivalence back to the patient using their expressed concerns. For example “You said that the opioid is used to control the pain but they aren’t working very well anymore. What makes you want to continue taking them the same way?”
Avoid argument and direct confrontation because this can reinforce a defensive oppositional stance in the patient. Instead recognize patient resistance is a signal that you might need to listen more carefully or change direction and reframe the conversation. Adjust to resistance rather than opposing it directly. This is often called rolling rates of resistance.
The simplest way to do this is to go back and reflect what the patient just said in a neutral way. For example “Are ready to think about planning to reduce your dose yet?” You can also use this as an opportunity to reframe the conversation. One way to do this is to express caring and support for a goal the patient has indicated is important to them. For example “I care about you and want to help you get back to being as active is you would like.”
And finally support self-efficacy and optimism by reinforcing signals that the patient is considering change. For example, “I think it’s great that you want to hear more about other ways to manage your pain.” You can also increase patient self-efficacy by providing credible, clear and actionable information. For example, most people can function better without worse pain after tapering opioids. Many patients have improved pain after a taper even though pain might briefly get worse at first.
Here are the five principles of motivational interviewing again. Effective motivational interviewing can take time and is very unlikely to change patient behavior in a single session. But it is one of the most effective tools we have for getting patients to consider behavior change and to help them prepare for a successful change.
In motivational interviewing one principle is to avoid argument and direct confrontation. But sometimes there’s a conflict between the patient’s wishes and your clinical judgment that can’t be ignored. In the end you are writing the patient’s prescriptions and you are responsible for the patient’s care. So how can you address these conflicts effectively?
In motivational interviewing argument and direct confrontation are generally voided. This six-step process is adopted from Joshua Sutton and co-authors protocol for patient-centered counseling to reduce use of low value diagnostic tests. It can be applied to any situation where your clinical judgment conflicts with the patient’s request such as patients asking for opioids for fibromyalgia pain when you don’t believe opioids will be effective.
In the next few slides we’ll walk through each step. The first steps are similar to those we reviewed for motivational interviewing. First understand the patient’s concerns and expectations before addressing them. Ask open-ended questions. Paraphrase what you hear so that the patient feels understood and you can make sure you will address what really matters to the patient.
Next validate the patient’s concerns and emotions using empathy and normalization. For example, “I can only imagine how frustrating it must be when the pain keeps you awake or most people feel even worse after their pain keeps them awake.” Inform the patient about reassuring features of the history and examination. Then explain that you do not recommend opioids because they’re unlikely to effectively reduce fibromyalgia pain more than temporarily and the risk of dependence and overdose outweigh these minimal benefits.
Allow the patient to respond. If she expresses additional concerns or emotions such as anger go back to step two with additional impacted statements. If the patient responds with additional angry statements continue to respond with multiple rounds of empathic statements. Next flexibly negotiate alternatives. For example, trial a good tricyclic and re-evaluation soon. And finally explore for residual concerns.
Here are all six steps again. In summary there are three types of clinical situations where good communication with patients about opioids is critical along with some of the specific things you can do to increase your effectiveness. When communicating important information pause and ask the patient what they heard. Correct misunderstandings and check for questions. In motivating behavior change express empathy through reflective listening, develop discrepancy between patient goals and behavior and support self-efficacy and optimism. When addressing conflicts understand and validate concerns and emotions and clearly explain your recommendation given benefits and risks.
I wanted to let you know about CDC’s new Opioid Guide App. It’s free and available today from Google Play for Android and coming soon to iTunes. The app includes tips and practice for motivational interviewing as well as an MME, dosage calculator and prescribing guidance. I’ll now turn the floor over to Doctors. Joseph Merrill and David Tauben who will discuss effective communication and specific challenging clinical scenarios.
Dr. David Tauben: Thank you Debbie. This is David Tauben. I’m sitting side-by-side here with my colleague Joe Merrill. We’ve been nicely introduced and I’ll just jump right into our case learning objectives. And Joe’s going to be advancing our slides for me. There we go.
So case learning objectives first is develop a specific communication strategies for two domains, one about transition to long term opioid use from a short term acute phase, a very key component because patients have to start on the opioid short-term before they get onto the long term. And then secondly when patients are on the long term either as a result of your own prescribing patterns which have been indoors for decades or inherited patients as mentioned before, strategies to change that group because they are very, very different populations.
And we hope Joe and I, that the result of our presentation of our case that you’ll be able to more successfully contrast the challenges that you’ve had and then compare with what we’re doing and maybe advanced a little bit along the way towards our long term goals recognizing that this is not done easily and this is a challenge which is why we’re speaking with you today.
So first case is a gentleman who’s – excuse, a woman excuse me who was referred to me from one of our primary care practices. The concern was in the 37-year-old woman that she had been on opioids now for about eight weeks. And this is getting into the transition phase and to chronic opioid therapy.
What I learned both from the primary care providers’ focus and extended discussion and the patient was that there was really no previous history of neck difficulties of the medical problems. She enjoyed her clerical job. She had two young children. She’s been smoking for quite a number of years but is working to get off and she described herself as a social drinker. Nothing remarkable about her family that would raise any red flags.
It was fairly common fatigue, poor sleep, headaches that she felt were coming up from the neck, but no neurologic complaints. And her exam was remarkable for a myofascial pain complaints following a spring strain in the neck. She had been through two prior physical therapy sessions, just two which she didn’t think helped. That was early on.
She had some plain x-rays from the day of injury which were unremarkable. And per CDC Guideline and basic goal treatment guideline these days her patient reported outcome we call pain metrics over here the PED, pain intensity was very high and interference with the enjoyment of life very high and interference with general function again very high. So she scored very high on a number of distressed scores.
Her THQ4 was also elevated at eight. A quick reminder I spoke about this in our first session that four times three questions is 12 so eight is above half weight at 2 which is how a primary care doctor can quickly decide if there’s an anxiety and depression present. And fortunately her opioid risk tool which is one of the many tools to be use identified low risk. I took a look at the situation, completed the exam as described and identified to her that a 60, six zero morphine equivalent dose which is hydrocodone six up to ten a day was not a good long term strategy and noted that she was on methocarbamol a muscle relaxer without much evidence of benefit with long term use and on cyclobenzaprine as needed and reminding the audience that cyclobenzaprine is a categorized as an tricyclic antidepressant drug. So that to me would be a reasonable evidence-based approach to managing this pain.
So the response to her when I brought up this – “I think it’s time to kind of come down off the opioids” was not a happy patient. As you can see please, please pleading with me to refill her medications and telling me that she certainly could not manage her job and family if I were to do that and shifting the onus to me to do something that differently.
So it was certainly a great opportunity for Dr. Merrill who’s been one of our leads here in motivational interviewing instructing and in the pain and opioid challenges that we’re now facing. So Joe what you call this kind of problem and what do we do next?
Dr. Joseph Merrill: Thanks David. So I think the first thing everybody who has this kind of conversation you get that feeling oh gosh now the patient is not on the same page as me there’s – just recognize that this is a hard situation. We don’t like to be in conflict with our patients. And for me one of the great things about motivational interviewing that allows me some tools to use to try and cut through that discomfort that we’re both viewing the patient and me.
So identifying this as resistance talk is the first step. And then really trying to get a sense of “okay when I hear resistance how can I roll with that? What do I need to do?” Well I need to make sure that the patient understands me, that the patient understands me. And the only way that’s going to happen is if I really understand what the patient’s saying.
So I really want to go with what the patient’s saying and say, “You know, tell me about how these things are helping you, what are they doing?” So this patient with her high distressed scores I’m expecting something like well it takes the edge off after work. It helps me go to sleep — something like that where which really is not why we’re giving her the opiate but I expect to hear some version of that. But I really want to understand and reflect back what her concerns are. That way she’ll be able to hear me later on.
So if you can get that kind of thing going then you can also then try and understand what she is really worried about. She’s worried about her job, she’s worried about her family, she’s worried about her sleep. She’s is worried about is this ever going to go away. And getting it so that you reflect that and the patient feels heard is really great. That – once you get that then you can kind of go the other way. “What about side effects? What about for you; are they working as well as they did before? Have you developed which to me is developing tolerance?” She’s likely to have some of that after two months of treatment. And so you can start getting a little bit more balanced picture of the pros and cons from her perspective.
Dr. David Tauben: Yes so that’s great Joe. And I worked with you for quite a while and I used these techniques and I thought I was really doing just great because she reviewed it. She was a little worried as we mentioned and has not significant concerns about side effects. But, you know, her husband was a little expressing some concern and she has been paying attention to the news that this is not a good idea.
So I said, “Well let’s start talking about how to move you off your medication.” I said, “Let’s start talking about a dose reduction plan.” And boom that kicked off another firecracker. And she was even more distressed though when we – she realized I had gotten her to the point we’re going to move to the plan I had proposed.
And so her comment was, “Well like you’re not just going to take away my pain pills are you?” So that’s another stumbling block that many of us have. And I just, how might you reframe that? We’ve got some strategies lined up on this next slide.
Dr. Joseph Merrill: Yes so, you know, again you’re getting resistance so and you have to decide as a provider sort of where are you in terms of safety. Is it – is it safe for you to continue these medicines or do you really need to do something right now? And in this case, you know, she’s been on them – I’m not saying she didn’t end up in the ER with an overdose. I have some time. I can do some more education, some more reassurance and move the process along.
So I can kind of diffuse some of her acute anxiety by trying to end up talking about our goals, what kind of, you know, want we want to do in the long run is to help you take care of your family, get you working and really then assess what, you know, what her concerns are that she had withdrawal symptoms or is she just worried that she’s not going to be able to sleep at all? And so if you can get those concerns you can have – be able to develop a menu of options so that she can feel better about eventually going down.
You know, so instead of me arguing with her it’s me against you it’s like we’re both looking at – we’re both looking, we’re side-by-side. We’re looking at the situation, yes you’ve identified some issues that are problems there. The guideline that I’m looking at I have concerns what – how are we going to manage this together?
Yes so very helpful. And I want to just share with the audience in the work that Dr. Merrill and I have been doing that these quotes that we’re providing for you consider them a script, a script that you would read if you were delivering in a theatrical performance. And this is not theater.
It’s a very different script than writing the opioid script. And the fact that the words are the same I think are a bit ironic. And with our trainees, the fellows, the residents and students that whom we work with regularly we put this down on paper and we have them actually practice these lines or just remember how to say these so that when it comes up you’re ready to say our shared goal. And then you can look them in the eye and you say are we on the same page, another moment to reflect back that the patient is actually in agreement with you by taking care of your family which was the first concern. I’m not going to be able to manage my family and my job. You’re actually reflecting that directly back.
What are your concerns again having a script in mind in advance. We’re practicing it. One of the students actually had it on a piece of paper when they went in the room. He knew this was going to be a problem and they found it somewhat useful. Certainly more experienced clinicians are comfortable with this and they get to it more easily but it’s something that if you’re not accustomed to doing you won’t remember how to actually say it.
It’s great working with Dr. Merrill because she reminds me every time when we’re in a conversation like this discussing the patient to say Dr. Dowell, you remind them of about that it’s a upside down side shared conversation for instance? So these are really very practical tools for preventing the transition from short term acute pain to long term opiates because when you get to that next setting like we’re going to talk about next it’s far more complicated. Now Dr. Dowell mentioned that the guideline specifically characterize patients whom – who have been on opiates for a long period of time represent a very different and specific challenge.
So this next case presents is a 48-year-old who I saw after his spinal fusion. His original back pain problem had occurred about six, eight years before. He was a stevedore for those of you who don’t live in coastal waters like in Seattle that’s one of the guys who works on the docks and does a lot of heavy lifting and carrying.
He’d been very successful I and been promoted so he’s in a management role so he wasn’t doing much of it. But in the course of a busy day, bad weather someone didn’t show up and he was down a bit unprepared and hurt his back. So this is about six years before he even got to the spinal fusion.
He underwent laminectomy and discectomy and unfortunately that surgery left him with an achy back and he continued to plod along but in the course of the ensuing few years he ended up on chronic opioid therapies. So he’s now been on opioids six plus years post spinal fusion, disabled, has not been back to work since the fusion procedure, married, three kids and busy years to be a parent, for those of you eight to 14, continues to smoke tobacco, denied current use of alcohol.
Family history as noted the lung cancer from smoking in his dad and has some cough from smoking, identifies constipation and reduction in libido which was a concern to him and at least he thought it was a concern to his wife but was still a personal concern from his personal perspective. So we checked again our pain metrics and PED tool again. And you can quickly eyeball this on your slide that again nine or ten for the pain intensity, pain infringes on the enjoyment of life and pain increases with daily function so again high level of distress.
His PHQ-4 was a bit lower than I would expect. Remember the earlier case of the patient telling us the PHQ-4 was an 8. So six is right at that threshold halfway to 12 where it becomes significant. And I must say I was figuring he was underreporting this likely a bit which is common but nonetheless he did endure some distress.
His opiate risk tool was moderate. And it’s moderate because he admitted in the tool that he had had problems with alcohol the past. So and he also checked off that he was depressed even though he didn’t endorse that in his PHQ-4 to the degree that he endorsed it on the checklist in the opiate use tool again, demonstrating that if you look at the problem in a couple of different ways you may get a better answer. He’s been a great patient for the previous provider and a really likable guy. And all his urines were compliant with toxicology which was – has been very appropriate (leads) and his prescription drug monitoring plan again confirmed that we were the only prescriber.
Again we’re back in this conundrum where his opioids working equivalents so 60 twice a day of morphine it’s 120 and hydrocodone eight times ten a day that’s 80. So 120 plus 80 is an NED of 200 — clearly above levels that we’d like to continue the patients currently. And to me at that point was more troublesome as he was on carisoprodol, brand name Soma for which we have little evidence of any benefit and compelling steps for discontinuation — plus lorazepam which he said he was using for sleep.
So his exam again very briefly showed he was a bit overweight. He was grimacing some but, his gate was normal, no worrisome findings on how patient exam and neurologic exam, a typical non-dermatomal, abnormal sensation to light touch which he says has been a problem ever since he’s had fusion surgery, again nothing even a yellow flag level.
Now I had some imaging to be again reassuring that the flexion extension showed no movement through the fusion site and his MRI fortunately did not interfere with the hardware. We got a pretty good view of the concern and sort of what you’d expect with a 48-year-old guy who’s done laboring and has been as I say too many under the influence of earth’s gravitational field carrying heavy weight.
So when I reassured him of this next step I was reminded of directly out of the CDC guideline is the specific recall that these are difficult patients to transition. It’s important to go slow. We need to give the patient an opportunity and here’s where motivation kicks in and we’re going into more detail in a moment to reevaluate their use so they’re participating discussion. They’re going to be empathic, get to the space where the patient is, reviewing benefits and risks, working with them in a patient self-management strategy and a shared medical decision mode and to identify that if we’re going to introduce a taper we need to go slow, we may take pauses and that your anxiety and depression may be a bit worsened during this possibly even your pain.
And of course when I mentioned that this is the plan that I’m contemplating leaving it to an open-ended question the next response was, “But Doc I can’t even manage on my current dose. Don’t you see my high numbers there? My pain is nine over ten. I need more opioids not less.”
So the easy part is presenting the case. The hard part is what Joe is going to be talking about because he pushed back with resistance. He said, “No way I can taper. My life is as bad as it can be right now. You’re just going to make it worse.” And then the ultimate threat and I think we’ve all heard, “You’re going to make me lay in bed all day and the full catastrophe is about to ensue if you take away my opioids.”
So Joe what do you think? How do we get – untangle this in a way that fits the motivational interviewing and the patient engagement strategy that we’ve been talking about so far?
Dr. Joseph Merrill: Well yes – this again you’re facing a difficult situation. And I think it’s just realistic to understand that if you’re going to be trying to do the right thing for this patient that you – there’s going to be some of this resistance because he’s been doing this for a long time. You can think of it as the big, you know, the steam liner going in one direction for years and you’re trying to just sort of nudge it around the corner. And it can take a lot of conversation to get to that.
But again remember you’re just heard resistance talk. You’re trying to elicit change talk. So you’ve got to get on the patient side. You’ve got to understand what they’re up against so how are they helping you? Again how are they helping you and then what concerns and fears and worries do you have?
And in this case I really think that there’s going to be some mileage to focusing on some of the negative aspects of the opioids because we’ve done a number of studies looking at like what patients attribute, negative things that patients attribute to their opioids. So this is the kind of patient where I suspect there’s going to be quite a bit of that.
And the way to think about that are, is it making him depressed or does he attribute some of his depression symptoms, fatigue? Fatigue he might have trouble concentrating. He may have low energy. These are symptoms of depression but they may be worsened by the opioids and especially the other medications as well. So you want to try and elicit those.
The other set of concerns the patient may have would relate to symptoms that are overall control of the medication. So these are addiction like questions. You know, he’s clearly been able to control the medicine. He hasn’t gone out and got them from somebody else. It’s always in adherence but that doesn’t mean he doesn’t have an opioid use disorder.
He could easily have tolerance. He could easily have withdrawal. And he could also have tried to get off these before and had no luck. He does have a risk of having an opioid use disorder related to just given the fact that he’s had an alcohol problem in the past. That really elevates his risk.
So I’m actually trying to – he also is a smoker. So he’s smoking a pack a day. He has a history of alcohol and he’s been using opiates for a long time. So I’m almost half expecting that I’m going to find something eventually. It may not happen this visit but I’m going to certainly ask and about his family and what do they think. And likely there are going to be some issues somewhere that we might be able to get around to actually diagnosing an opioid use disorder.
And again that can be a big conflict if you’re starting to present a new diagnosis in a patient oh, it’s all – this is all related to my pain. But at the same time you can try and measure that or help them understand that opioid use disorder is not a bad person doing a bad thing. It is someone who has experienced opioid therapy for a long time and thee have been complications to it.
So that can really it can be a hard conversation but it can be very effective. I’m actually thinking this guy rather than a taper maybe he should be a patient who’s getting buprenorphine treatment for an opioid use disorder. It would tremendously reduce the risk of overdose. And a lot of patients who’ve been on opioids for this long they can’t get off of them completely. But lowering the dose or switching to suboxone they just feel a lot better.
They can – they have more energy, they can concentrate, they can get on to other things. And the other kinds of medicines that we may use, non-opioid medicine and not medication strategies for their pain may actually be more effective in that setting. So that’s kind of where I’d start. It’s – there’s always a lot and it can take some time.
Dr. David Tauben: Yes it sure can take some time Joe and I think that’s so helpful to mention because how are you going to get the time in your visit? This is a common question in much other providers of pain care where they say I’ve got a ten, 15 minute visit. I’ve got seven other active medical problems. I’ve got preventive health maintenance and then I’ve got that electronic health record and I’m running 45 minutes late. How am I possibly going to be able to introduce this in the visit as scheduled? You may have scheduled a longer visit for this time but your schedule is pretty jammed. So, what are the strategies I know that you’ve proposed about having the patient on return move to different stages that you’ve set up in preparation at this visit?
So some thoughts about how we make time out of thin air or how do you find it in real life and real-time care of patients because developing this relationship cannot be done staring at a computer? It cannot be done in a five minute visit.
Dr. Joseph Merrill: I think that’s a great point. And I, you know, I think the first thing you’ve got to figure out is what’s the urgency here? You know, how safe is this? Well it’s not. It’s not safe but, you know, is this urgent?
I mean if this same patient showed up in my office after an overdose and was seen in the ER I would have to do something now. I – and I would do something now. And I would just reflect back that this is obviously not safe and we need to do something different. And but more often and I think in this patient he’s done okay. I mean he hasn’t done well. He’s not doing well clinically but it’s very chronic. So you do have time to start establishing rapport. And that’s really important.
You have to make sure the patient really feels heard in order for you to be making progress that is sustainable. And that is progress that you’re both – you’re not the doctors who never listens, you’re the doctor who’s trying to help them. And that is – that’s really the main thing.
So take time when you have it. If you get a lot of resistance talk about their diabetes and their hypertension for a while and get back to it. But a lot of times patients really need to hear some of these things more than once from their doctor to start to buy into it. And you may be able to get them to some other providers who have similar statements and so he’s getting it from more than one person.
Dr. David Tauben: You know, that’s great and then there’s a strategy that I found occasionally helpful as well is on the first visit remembering the CDC guideline that it doesn’t have to start right away. It’s not an acute urgent problem. There’s – when the patient pushes way back on me I’ll say, you know, this is just an opening conversation. When you come back and in your next visit and let’s make it in about two weeks rather than the usual month or three months basically to keep the dialogue hot and the conversation still going. And we’ll explore it more.
So I’m not going to throw anything at you right now. I’m just going to learn more about you. You’re going to learn more about me and we will do this in measured time. Often in my own mind we’ll say the first – next visit will be just a discussion. The visit after that will be to get some shared medical decision-making and not actually start to taper until visit three or visit four if it’s still reasonably safe.
Now this is a twisted problem because it’s not just about opioids. He’s got carisoprodol and benzodiazepines. So how might you introduce the combination of three different target agents? And the guy’s pretty overwhelmed.
You pick one of the three? Do you let them pick which ones? Let – I don’t think there’s any clear evidence on this. I’ve not seen it published yet but I’m sure Joe, you have you have an opinion based on your experience so far.
Dr. Joseph Merrill: Yes well this is really a tough one. And it would be a tough one for me doing this the first visit just because I don’t prescribe carisoprodol. I just don’t. I have – I – it’s got metabolites that are barbiturates that put people at risk to die. And I – and they – so I see it as a really problematic medication. And I would be looking for every opportunity not to prescribe it. And sometimes if you raise issues around all the benzos and the opiates and it’s not a safe dose some patients might be willing to give up the Soma. And I’ve actually had luck with that sort of say, you know, putting kind of a – and it kind of is putting my – a little bit of a boundary around my prescribing that I would really try and do that.
Now would I do anything else besides stop the carisoprodol, probably not in a patient who is really doing a lot of resistance talk but I’d probably, I mean it is my prescription and I don’t want to prescribe that stuff.
Dr. David Tauben: So we’ve got to take our own ownership there. So in a bit of a summary this is to launch off of the conversation that we’ve just been having about location. I’m just going to run through what Joe and I and collaboratively identified are kind of four general principles that are associated with empathic communication with this increased skill set. So as mentioned by all of us. Be reflective. Listen and reflect back to the patient on what you’ve heard. If they feel listened to, they feel you understand them and they would expect someone who will be a little bit more sympathetic to their needs and requirements by reflecting. So time for listening is hard. It’s important to find and quality listening can actually take place in the shorter time than interrupted and distracted listening.
Using nonjudgmental language, very important, using words like ‘bad’ or’ you shouldn’t’ or ‘what was that other doctor thinking when they did it’ never helps. It just increases all of the resistance that we’ve been talking about previously. So be very careful and almost coddling in the language that you use to have the patient feel that they’re in a comfortable place.
Thirdly affirmative statements, affirmative statements positive. And they’re affirmative statements that the patient may have made. In the course of their response to one of your open-ended questions if you hear anything positive in that go back to that again. A patient may have said, “You know, I did miss a dose and it really wasn’t that bad.” I wouldn’t interrupt them and hold it and bring it back later. That’s again reflective. That allows you to call back something that they said reaffirming that you’ve been listening but also giving them the chance to speak to some of their ambivalences.
This patient for instance had a reduced libido. And you could say for instance “Your libido’s down. Were you aware that the opioids are real libido killers? They do it directly and they impair all sorts of other functions.” and an opportunity for him to say “Yes, I know that was a problem and maybe that’s a side effect that I wasn’t even aware of.” But arguing is not going to go anywhere. And the only arguments is when it’s absolutely certain you’re not going to do it because it’s not safe.
And finally it’s a mutually agreed-upon taper plan. It becomes their taper plan. I won’t mention this gentleman’s name. I’ll call him Tim for instance and after we have an agreed plan that we’re going to start taking this -our carisoprodol down one dose less a week over the next couple of weeks and then we’re going to review what the schedule’s going to be. He’ll say, “That’s fine.” I say, “Maybe three or four months we’ll be tackling the opioid plan.” He’ll likely say, “Sounds fine Doc.” I will call it the Tim opioid reduction plan that is starting at three or four months. So he owns it. He has a responsibility for it. And I will reflect back that this was a shared decision that we made a couple months back and I’ve been paying attention to it. I’m taking it seriously and I hope he has taken it seriously too so it becomes a shared plan.
So we have time now for questions. I think we have about – it was up to ten minutes of questions. So I’m going to put this – our phone down here and open it up to our CDC colleagues to lead the questions. I think we’re ready. You’re going to come on board now?
Dr. Loretta Jackson-Brown: I am here. Thank you so much presenters.
Dr. David Tauben: Great.
Dr. Loretta Jackson-Brown: That was a wonderful, wonderful overview of how to effectively communicate to patients about opioids. And so now we’re going to open up the lines for the question and answer sessions. And remember questions are limited to clinicians who would like information on prescribing opioids. For those who have media questions you’re going to have to contact CDC Media Relations at 404-639-3286 or send them an email at firstname.lastname@example.org.
And if you’re a patient please refer your question to your healthcare provider. When asking a question go ahead and state your organization and also remember you can submit questions through the webinar system. Coordinator?
Coordinator: Thank you very much. At this time we’ll begin the question and answer session. If you’d like to ask a question from the phones please press Star 1, make sure your phone is unmuted and record your name. To withdraw that request you may press Star 2. Once again for audio questions press Star 1 and record your name. We’ll stand by for questions or comments.
Dr. David Tauben: Okay so while we’re waiting for our first question one of the questions that I had during the discussion that I think is worth exploring. Dr. Dowell, in her principles of motivational interviewing earlier on used the phrase develop a discrepancy between the client’s goals or values in their current behavior. So develop a discrepancy between their goals and values and their current behavior. I’m going to ask Joe to give an example perhaps or help iterate that a little bit more clearly because it’s not clear why I would want to create a discrepancy. I want to be in alignment; I don’t want to be discrepant. So while we’re waiting for the other questions, Joe, just a couple of words on what that means and how we can accomplish that?
Dr. Joseph Merrill: Well I think that this developing discrepancy is really not a discrepancy between you and the patient. That’s important. It’s a discrepancy between – it’s basically highlighting the ambivalence a patient may feel around their opioids.
So it’s unlikely that the patient feels good about their opioids but they’re really doing a great job because the patient’s having such high scores on their pain and function problems they’re kind of probably feeling like they aren’t working as well as they did, that there’s other – but they’re still taking them. So that in some ways is a discrepancy. They’re continuing to take them but they’re not working very well.
That’s – and so or taking them in order to be able to function but they’re not functioning well. So it – that’s the kind of discrepancy you’re looking for. If you can get it all from the patient that’s great. In other words ask what are your concerns about opioids or how things are going now. But sometimes the patient may not of thought of the libido problem or the concentration problem or even the sleep problem or the energy problem.
So in a motivational interview we don’t usually do a lot of education. When you find yourself educating the patient you’re supposed to stand back and say, wait, wait this is – it should come from a patient as much as possible. So – but you can ask the patient would you – would it be okay for me to tell you what some of my other patients have found when they tapered their opioids? And then you can provide some context that really is your context for your concerns. And then you’re also seeing patients who have done well when they tapered so you’ve got to share that information somehow.
Dr. Deborah Dowell: And this is Debbie Dowell from CDC and I’ll just add to that. You know, as Joe said I think we know that a lot of patients are ambivalent about opioids even if that’s not the first thing they express. But we know from surveys of patients that have been on opioids long term a lot of them do feel ambivalent so to the extent that you can ask them, you know, how well opioids are working, if they have any concern and use the patient’s own language and concerns.
And this is, you know, motivational interviewing is kind of subtle. You don’t want to confront the patient and say, “You said this but how could you say that,” but really kind of just in a very neutral way reflect back, you know, “You said that the opioids used to work very well but they’re not working as well as a more and your main goal is to be able to take care of your family without having the pain interfere? Can you tell me more about that or, you know, tell me about what you would like to be different?”
I think and as Joe said, you know, it’s really kind of it – you’re developing a discrepancy between two different things the patient has said, not between you and the patient. And to the extent that you can allowing the patient to articulate that themselves is going to be the most effective.
Dr. Joseph Merrill: This is Joe. Just another way to think about it one of the key things in motivational interviewing is doing reflection. So you get – and one of the best kinds is this double-sided reflection. “So on the one hand you can’t imagine being off these opioids. They’re hardly controlling as much of your pain. And you think that you’re going to end up in bed if you even go down a little bit. On the other hand you have these concerns about the opioids.” So it’s not arguing with the patient. It’s presenting both sides of the patient ambivalence.
Dr. David Tauben: Okay we have any other…
Dr. Loretta Jackson-Brown: Yes we’ll go back to the phone coordinator.
Coordinator: Yes. We do have three questions from the phones. And our first question or comment is from Steven Linder. And please state your organization.
Steven Linder: I’m with the Veteran’s Hospital in Palo Alto, California.
Dr. Loretta Jackson-Brown: Go ahead with your question.
Steven Linder: A very comprehensive talk although I was wondering particularly with the last patient at what point will you also bring up the OEND, Overdose Education Naloxone Distribution for these patients.
Dr. David Tauben: Let me just jump in that. I did it at the first visit. You know, we didn’t cover that and it’s a great point to remind our audience that any patient at risk — and he’s certainly at risk with the sedatives and the benzo and the opioids — that – is that helps actually a bit of the motivation interviewing because then I lay out that from my perspective this is a – is such a risky drug that I want he or – and his loved ones to have on hand drug to rescue him from death. And it’s a pretty strong statement and I use very strong language and I hand the prescription.
I must say depending on the level of engagement about half the patient’s say, “That’s fine I’m never going to pick it up.” They’re still in resistance mode here. But I have offered it and that can become a continuing conversation. But yes (Steve) great point. It’s anytime you see risk it’s part of guideline and it’s frankly part of good safe opioid practice in general. Thanks for bringing that up.
Dr. Deborah Dowell: And this is Debbie Dowell from CDC. And we do recommend offering Naloxone to patients who are at high risk including, you know, patients with characteristics this patient had as David mentioned on benzodiazepine, on dosages over 50 as well as patients who’ve experienced overdose and patients who have substance use disorder. And I think it’s a great way to show that you’re partnering with a patient to prevent their risk and also underlying the risk of these drugs in a less confrontational way.
Dr. Loretta Jackson-Brown: Coordinator next question please.
Coordinator: The next question comes from (Ronald). Your line is open.
Ronald Bergman: Yes this is Ronald Bergman. I’m in Bellingham, Washington. Hi Joe, Dave and Deborah. Thank you very much for an excellent presentation. I have a couple of thoughts I’d like to throw in. Are you hearing me okay?
Dr. Loretta Jackson-Brown: We are. Go ahead with your question.
Ronald Bergman: Okay whenever I approach patients and have to make decisions with the patient I also want to rely very heavily on offering them alternatives. There’s lots of good articles on evidence-based complementary help. You know, and some of the alternatives obviously are massage, acupuncture, biofeedback, diet, exercise.
I also encourage patients if they’re interested to join a group like a fitness group or go to the pool where they get group support in terms of in this whole process. And I agree that in fact you introduce the tapering to a patient then you go slowly over a period of time and in this same period of time and you’re doing the motivational interview and you’re also adding in the possibility of alternative things that they can do.
And I also agree with Joe reflecting back on patients that you’ve previously seen that have been successful in this that often is very helpful and they – you may even mention that some of the patients are still in the group in the pool and they may in fact join them. And lastly I always – I always use very heavily the case review and recommendations I received from the University of Washington case management cases.
And also I rely very heavily and thank you very much CDC for providing us with these excellent Guideline. I use the Guideline a lot discussing with patients and I very, very seldom get a lot of argument when I use these resources. Thanks.
Dr. Deborah Dowell: This is Debbie Dowell from CDC. Thanks Dr. Bergman and yes I think these are excellent points that this is multifaceted. And while you’re worrying about the patient’s opioid dosage, you know, you need to also be working on other approaches to their pain. And I would refer for those that haven’t already joined or listened to it COCA webinar 1 in the series on the CDC Guideline for Prescribing Opioids for Chronic Pain deals with non-opioid approaches to pain including many of the approaches you mentioned.
Dr. Loretta Jackson-Brown: Coordinator do we have another question from the phone?
Coordinator: We do. The next one is from (Dolores). Your line is open.
Dolores Turner: Yes I’m Dolores Turner. And I work on occupational health. And I have seen patients coming from pain clinics in the use of methadone. And I was wondering if you’ve seen this in your practice?
Dr. David Tauben: Yes this is David Tauben. Yes methadone for chronic pain has a number of reasons why it became so popular. It’s was the first of the long acting opioids even before the extended release opioids came out. So there’s a long history.
Methadone is an analgesic as many of you do know. It was a – developed as a pain reliever. But because of its long acting and duration of affect it also became a drug used – an opioid used for medication assisted treatment programs, i.e., a methadone maintenance program. So use of methadone for pain that’s the most inexpensive but unfortunately it has an enormous number of complexities.
But the first is, is it is a very variable does duration from seven hours to seven days. So inter-individual variability in metabolism is the highest known reported for any opioid use. And so you clearly can’t tell based on looking at your patient how they’re going to handle the drug. It also is 100% cleared by the liver and therefore every other medication the patient may be taking is going to be interfering with the cytochrome and other mechanisms of the metabolic affect.
And its own metabolism is interesting because it not only inhibits, but it induces enzymes. So the initial induction of the inhibition makes its half-life more rapid but it’s inhibition of its own metabolic pathways is a challenge and hence it is more potent and higher doses over longer period of time in a nonlinear fashion. So for all those reasons it’s complicated.
The strategies for management however that we just went through are identical. Unless the patient is on the methadone for unrecognized opioid use disorder which is commonly the case that the very high dose patients on methadone in the 60, 80, 120 milligrams doses that are used for methadone maintenance are providing a de facto treatment for their opioid use disorder. And it’s the diagnosis of opioid use disorder present unless you are licensed in a methadone maintenance program or and hopefully everyone who has DA authority potential to be buprenorphine trained should receive that alternative and approved and legally sanctioned medication addicted program not under the guise of pain but treating it as it is.
So in a pure pain setting the taper is going to go slow. It’s going to go long and with the same techniques and strategies that you’re talking about are applicable. I’m not sure if that answers Dolores your question adequately but we do encounter it. We encounter it regularly and it should be considered another opioid with its own unique complexity. So it’s very important that everything I briefly mentioned is well known by a prescriber in terms of its additional potential risks.
Dr. Loretta Jackson-Brown: Thank you. Operator we have time for one more question.
Coordinator: I show no questions in the queue at this time. That is Star 1 for a question.
Dr. Deborah Dowell: And this is Debbie Dowell from CDC. I’ll just add to Dr. Tauben’s answer to the last question. For all the complexity that he mentioned for all of those reasons the CDC guideline recommends that methadone be not be considered a first line extended release opioid even when you’re using the extended release opioids and that when methadone is used for pain. It should only be used by prescribers who are familiar with these complexities and prepared to educate their patients about them.
Dr. Loretta Jackson-Brown: Thank you. On behalf of COCA I would like to thank everyone for joining us today with special thank you to our presenters Doctors. Dowell, Merrill and Tauben. The recording of this call and the transcript will be posted to the COCA Web page at emergency.cdc.gov/coca within the next few days. Free continuing education is available for this call. All continuing education for COCA calls are issued online through TCE Online the CDC training and continuing education online system, www.cdc.gov/tceonline.
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Coordinator: That concludes today’s call. Thank you for participating. You may disconnect at this time. Speakers please allow a moment of silence for post conference.
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